Living Will Sample – Online Living Will Template and Blank Will Form

living will sample - example of a living will - blank will form

Use this Living Will Sample as an example of a living will for your estate. Copy our example of a living will in Microsoft Word to use it as a blank will form or use our affiliate’s online living will template.

Don’t let the courts or someone else decide what happens to your assets. Let the living will speak for you in case you can’t.

Living Will Sample

For an online living will sample from LegalZoom that you can fill out and complete in a few minutes, visit:

  • Online Living Will – living will template and fill in the blank will form (you can also view a detailed living will sample for your state)

Additionally, the following example of a living will may serve as a starting point:


LIVING WILL DECLARATION

I, [Declarant] , (“Declarant” herein), being of sound mind, and after careful consideration and thought, freely and intentionally make this revocable declaration to state that if I should become unable to make and communicate my own decisions on life sustaining or life support procedures, then my dying shall not be delayed, prolonged or extended artificially by medical science or life sustaining medical procedures, all according to the choices and decisions I have made and which are stated here in my Living Will.

It is my intent, hope and request that my instructions be honored and carried out by my physicians, family and friends, as my legal right.

If I am unable to make and communicate my own decisions regarding the use of medical life sustaining or life support systems and/or procedures, and if I have a sickness, illness, disease, injury or condition which has been diagnosed by two (2) licensed medical doctors or physicians who have personally examined me, (or more than two (2) if required by applicable law), one of whom shall be my attending physician, as being either (1) terminal or incurable certified to be terminal, or (2) a condition from which there is no reasonable hope of my recovery to a meaningful quality of life, which may reasonably be referred to as hopeless, although not necessarily “terminal” in the medical sense, or (3) has rendered me in a persistent vegetative state, or (4) a condition of extreme mental deterioration, or (5) permanently unconscious, then in the absence of my revoking this Living Will, all medical life sustaining or life support systems and procedures shall be withdrawn, unless I state otherwise in the following provisions.

Unless otherwise provided in this Living Will, nothing herein shall prohibit the administering of pain relieving drugs to me, or any other types of care purely for my comfort, even though such drugs or treatment may shorten my life, or be habit forming, or have other adverse side effects.

[Pregnancy]

I am also stating the following additional instructions so that my Living Will is as clear as possible:

[Resuscitation (CPR)]

[Intravenous and Tube Feeding]

[Life Sustaining Surgery]

[New Medical Developments]

[Home or Hospital]

In the event that any terms or provisions of my Living Will are not enforceable or are not valid under the laws of the state of my residence, or the laws of the state where I may be located at the time, then all other provisions which are enforceable or valid shall remain in full force and effect, and all terms and provisions herein are severable.

IN WITNESS WHEREOF, I have read and understand this Living Will, and I am freely and voluntarily signing it on this ____________________ in the presence of witnesses.

Signed: _____________________________

[Declarant]

Street Address: _____________________________

County: _____________________________

City and State: _____________________________

WITNESSES

We, the undersigned witnesses, certify by our signatures below, that we are adult (at least 18 years old), mentally competent persons; that we are not related to the Declarant by blood, marriage, or adoption; that we do not stand to inherit anything from the Declarant by any means, including will, trust, operation of law or the laws of intestate succession, or by beneficiary designation, nor do we stand to benefit in any way from the death of the Declarant; that we are not directly responsible for the health or medical care, or general welfare of the Declarant; that neither of us signed the Declarant’s signature on this document; and that the Declarant is known to us.

We hereby further certify that the Declarant is over the age of 18; that the Declarant signed this document freely and voluntarily, not under any duress or coercion; and that we were both present together, and in the presence of the Declarant to witness the signing of this Living Will on this_____________________.

Witness signature: _______________________________

Residing at: _______________________________

_______________________________

Witness signature: _______________________________

Residing at: _______________________________

_______________________________

Notary Acknowledgment

State of _______________________ )

SEAL

County of _____________________ )

 

This instrument was acknowledged before me on this _____________________ by [Declarant] , the Declarant herein, on oath stating that the Declarant is over the age of 18, has fully read and understands the above and foregoing Living Will, and that the Declarant’s signing and execution of same is voluntary, without coercion, and is intentional.

__________________________ __

Notary Public

My commission or appointment expires: _______________


Blank Will Form

Each state has different rules for living wills. To capture the nuances for your state, we recommend starting with an online living will sample. It takes about 15 minutes to fill out the blank will form and can save you high legal fees.

Online Living Will →

Use this living will sample to get your affairs in order so that your heirs don’t have to worry about what happens to your estate. They’ll be glad you did.

 

NOTE: Khera Communications, Inc. makes no warranties, express or implied, regarding the use of this document. In no event shall Khera Communications, Inc. be liable to anyone for any problem, claim, or loss arising out of the use of this agreement or related online tools. While the document displayed here has been carefully prepared, the final document produced should be reviewed by a lawyer before use. Khera Communications, Inc. is not engaged in practicing law nor does Khera Communications, Inc. provide legal advice. We recommend using the link to the Online Living Will document provided by LegalZoom.